Brain Box Request Form

Please note:

Due to cost and logistics reasons, we are unable to ship the Brain Box to addresses outside of New Zealand
Due to the significant cost of the Brain Boxes, and to ensure that the service remains free to newly diagnosed patients and carers, we are only able to send one Brain Box per residential address.
Brain Boxes are filled once a week, so please allow 7-14 days for delivery.

Name

First Name

Last Name

Email Address

Phone

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

This is for:

Please tell us whether the Brain Box is for the patient or their carer

Patient

Carer

PATIENT INFORMATION - please note we respect your privacy and do not share this information. This is used for our internal purposes and we like to make sure our brain boxes are tailored for you, so that you get the most out of the resources included in them.

Gender

Age

Which ethnic group do you belong to?

Tumour Type (if known)

Grade (if known)

Date of diagnosis

Message - Please tell us a little about your story.

Do you wish to subscribe to news and updates from us?

Yes, please

No, thanks

Privacy Statement

We collect personal information from you, including information about your: name; contact information; location; interactions with us and reason for contacting us. We collect your personal information in order to provide information, support, guidance and advocacy. We keep your data secure and do not share it without your permission (except in rare extreme situations to avoid a person’s health or safety being endangered). You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or to have it corrected, please contact us at hi@braintumoursupport.org.nz, or 0272923337.

Brain Box Request Form

Privacy Statement

Contact us

Office Address